Dear Parent,

Congratulations! By choosing a licensed Family Child Care Provider, you have made an important child
care decision for you and your family. The Department of Early Education and Care (EEC) now invites
you to join in a partnership with us and your Family Child Care Provider to ensure a high quality child care
environment. This fact sheet and enrollment packet outlines the information you must give to your
provider, and will acquaint you with some of the key EEC standards designed to ensure a safe, healthy,
educational child care experience.
The first day your child attends child care, you must give your provider a copy of the attached Family
Child Care Enrollment Packet. Without these completed documents, which must be updated annually,
the provider cannot care for your child. This requirement ensures that the provider has all the important
information and phone numbers he or she will need in order to provide the best possible care for your
child.
We encourage you to maintain an open dialogue with your provider, as communication between parents
and providers is the foundation for a solid working relationship, and a good child care experience. Before
filling out your child enrollment form, please read the important information contained in the parent fact
sheet below. Remember, EEC is always available as a resource to both you and your provider.

Look for the License

EEC has quality standards for all licensed child care programs to ensure high educational value, as well
as health and safety. A license means that a Family Child Care Provider has demonstrated that he or
she meets the standards outlined in the EEC regulations. To obtain your own copy of EEC Family Child
Care Regulations, you may download them from the EEC web site.
Enrollment/Capacity A provider may only care for the number of children he or she has been licensed
for. You can find out what your provider's licensed capacity is by checking the license, which is posted in
the home. Please note that a provider may care for no more than three children under the age of two
without an assistant. If you have concerns or questions about the number of children in your providers
care, discuss the situation with your provider or contact EEC.

Supervision
Supervision is critical to keeping children safe. Child care providers must directly supervise the children at
all times. This means that a provider must be able to see or hear the children without interference.
Use of Assistants If approved by EEC, a provider can have an assistant to help care for the child care
children. A provider must also inform the child's parent or guardian of the name of the assistant and
when the assistant will be helping the provider with child care.

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Medical Information
Medical information about your child must be given to your provider within one month from the day your
child begins care. There are three things your provider will need:
1. A statement from a doctor or health care professional that says that your child received a physical
exam within the past year;
2. Evidence that your child has been immunized as recommended by the Department of Public
Health;
3. If your child is nine months of age or older, a statement from a doctor or health care professional
which says that your child has been screened for lead poisoning.
Please note: Your child's immunization record must be updated and given to the provider in accordance
with the Department of Public Health's immunization schedule. Also, your child's lead screening report
must be updated as required by Department of Public Health Regulations. This report must also be given
to the provider. If your child is school age, the provider may accept from you a written statement that the
required information is on file with the childs school.

Safety
EEC has a number of licensing standards related to safety in a Family Child Care Home. Most of these
standards outline common safety precautions such as making dangerous materials inaccessible to
children, covering outlets, having a first aid kit, practicing evacuation drills, gating stairs, windows, or
heating elements, posting emergency numbers, and maintaining a clean, hazard-free indoor space. Also,
the outdoor space must be safe and hazard free and there should be no access to a busy street, water,
construction materials, rusty or broken play materials, debris, glass, or peeling paint.

Notification
The Provider is required by regulation to notify parents of certain information about the family child care
home. These notifications include, but are not limited to; injury to a child, communicable diseases
introduced into the child care home, identification of other caregivers, children being taken off the child
care premises, presence of firearms, change in household composition, pets and infant sleeping
positions.
______________________________________________________________________________

Curriculum and Daily Schedule

The provider must carry out a routine that is flexible and responds to the needs and interests of children
in care. The routine must include things such as; meeting the physical needs of children in care, thirty
minutes of physical activity every day, child initiated and provider initiated activities and daily outdoor
play, weather permitting. Additionally, the provider must develop a curriculum that engages children in
developmentally appropriate activities by planning specific learning experiences. The curriculum must
include things such as; learning self-help skills that foster independence, opportunities to gain problem
solving and decision making competencies and leadership skills and opportunities to learn about proper
nutrition, good health and personal safety. The Provider is also responsible for providing an environment
that promotes cultural, social and individual diversity.
__________________________________________________________________________________

Staying Involved
It is important to keep an open dialogue with your Family Child Care Provider, and to maintain an active
role in your childs care. Visit often, not just at pick up and drop off time, but at a variety of times during
your childs day. It is a parents right to visit at any time and in doing so; it will help promote a successful
experience for your child. High quality child care is a benefit to your entire family. Remember, you can
always call the Department of Early Education and Care with questions or concerns about your childs
care.
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Family Child Care Enrollment Packet

Please fill out these forms completely. If a question does not apply to your child, write N/A (not
applicable). The forms must be in the provider's possession on or before the first day your child
begins care. Please notify your provider if any of the information changes.

General Information
Date of Admission __________________________ __Date of Discharge _________________________
Child's full name ______________________________Date of Birth _____________________________
Address ____________________________________________________________________________
Telephone Number: ______________________________
Nickname ___________________________________Primary Language _________________________
Eye Color __________ Hair Color __________ Sex _______ Height __________ Weight __________
Allergies/Special Diets _________________________________________________________________
Name of Parent(s)/Guardian(s)___________________________________________________________
Home address (if different) ______________________________________________________________
Telephone Number:____________________________________________________________________
Parent(s)/guardian(s) location during child care:
Parent/Guardian: ___________________________
Where: ___________________________________
___________________________________
Telephone: ________________________________
Cell Phone: _______________________________
Instructions: _______________________________
_________________________________________

Parent/Guardian _________________________
Where: ________________________________
________________________________
Telephone:_____________________________
Cell Phone:_____________________________
Instructions:_____________________________
______________________________________

Emergency Contact/Authorized pick-up person

In the event of an emergency when I may not be reached, the provider may contact the following
individuals (in the order given) whom I authorize to take my child from the child care premises.
(1) Name: _______________________________ Address ____________________________________
Telephone ______________Cell Phone __________
(2) Name: ______________________________ Address _____________________________________
Telephone _____________ Cell Phone __________
I additionally authorize the following individual to take my child from the child care premises. (It is advised
that you notify the provider at the beginning of the day when your child will be picked up by one of the
authorized individuals.)
Name _____________________________ Address ________________________________________
Telephone ______________ Cell Phone ____________________
Childs Name ___________________

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Attendance
Day

Arrival Time

Departure Time

Day

Arrival Time

Departure Time

Monday

____________

____________

Friday

___________

______________

Tuesday

____________

____________

Saturday ___________

______________

Wednesday ____________

____________

Sunday

______________

Thursday

____________

____________

___________

Written Acknowledgement of Receipt of Parent Fact Sheet Information (See first two pages).
I acknowledge that I have received a copy of the first two pages of the enrollment packet (parent fact
sheet) developed by the Department of Early Education and Care.
__________________________ ______________
Parent/Guardian
Date

Parental Visit Notice

I understand that I may visit this family child care home unannounced at any time during the hours that
my child is in care.
_________________________ _______________
Parent/Guardian
Date

Child's Pediatrician or Source of Health Care

Name: ______________________________________________
Address: ___________________________________________

Telephone: ___________________

Medical Insurance Information (OPTIONAL)

Subscriber's Name: _________________________________
Type of Insurance: _________________________________

Policy #: _____________________

Childs Name ______________________

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Childs Schedule and Interests

The following information about your child's routines and activities will help your provider give your child
the best possible care. If a question does not apply, please write N/A (Not applicable)
Eating: Schedule ___________________________________________________________________
Food likes and dislikes ________________________________________________________________
Food allergies _______________________________________________________________________
Sleeping: Napping schedule __________________________________________________________
Please describe your child's fussy time, if any ______________________________________________
___________________________________________________________________________________
Please describe any special circumstances or needs (i.e.: stuffed animal, story, mood on waking, etc.)
___________________________________________________________________________________
Does your child sleep in a: crib?___________
bed? ________
Does your child sleep on his/her: back?_____ side? ______ stomach? ______
Please Note: The American Academy of Pediatrics has determined that placing a baby on his/her
back to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and
unexplained death of a baby under one year of age. If your child does not usually sleep on his/her
back, please contact your pediatrician immediately to discuss the best sleeping position for your
baby. Please also take the time to discuss your childs sleeping position with your caregiver.
Your provider will place your infant on his/her back unless there is a written physicians order that
specifies otherwise.
Toileting: Is your child toilet trained? _______ Schedule: ____________________________________
Please describe any recurring problems with toileting or diapering ______________________________
___________________________________________________________________________________
Allergies: Does your child have any allergies (food, medication, insects, etc)? If yes, is there any special
care needed? Also, please indicate specific instructions for the provider regarding your childs allergies.
___________________________________________________________________________________
___________________________________________________________________________________
Please describe your symptoms of your childs allergies _______________________________________
____________________________________________________________________________________
Play: Favorite activities: Indoor _________________________________________________________
Outdoors ____________________________________________________________________________
Fears: Please describe any fears your child may have ________________________________________
____________________________________________________________________________________
Child Guidance: Please describe the steps you take in managing your childs behavior at home:
____________________________________________________________________________________
____________________________________________________________________________________
Special Needs: Please describe any special medical, physical, or emotional needs your child may have:
___________________________________________________________________________________
___________________________________________________________________________________
Add any information about your child which you feel would help the provider in caring for your child:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Childs Name _________________
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Permissions
General Permission (Parents should not sign this permission unless specific places where your child is
allowed to go are listed by your provider.) By signing this form, I am allowing my child to be taken off the
child care premises.
I, hereby give __________________________________ permission to take my child ________________
(provider/assistant)
off the premises of the family child care home for the following excursions: (specific places your child is
allowed to go): _______________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
using the following forms of transportation: _________________________________________________
____________________________________________________________________________________
____________________________________
Parent/Guardian Signature

______________________________________
Date

I do not want my child to be taken off the child care premises.

____________________________________
Parent/Guardian Signature

_____________________________________
Date

Medical Emergency Treatment (Department of Early Education and Care recommends checking with
your local hospital about the acceptability of this statement)
I, hereby give __________________________________ permission to administer first aid and/or CPR to
(provider/assistant)
my child ______________________________, and/or take my child to a hospital for medical treatment
when I cannot be reached or when delay would be dangerous to my child's health.
____________________________________
Parent/Guardian Signature

_____________________________________
Date

Topical Medication/Ointments (Please list only those medications/ointments which you will allow the
provider to administer to your child's skin): Examples: sunscreen, bug spray, diapering ointment.
____________________________________________________________________________________
____________________________________________________________________________________

____________________________________
Parent/Guardian Signature

_____________________________________
Date

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Emergency Card Information

REMINDER : This emergency card information is for the providers first aid kit. The provider must
take first aid materials when leaving the child care premises.

Child's Name:____________________________ Date of Birth:__________________________________

Child's Home Address:_________________________________________________________________
_________________________________________ Phone: ____________________________________
Instructions to Reach Parent or Guardian
1.__________________________________________________________________________________
(Name, Address, Home and Cell Phone #)
2.__________________________________________________________________________________
(Name, Address, Home and Cell Phone #)
Contact Information for Pediatrician or Source of Health Care
1. _________________________________________________________________________________
(Doctor's Name, Address, Phone #)
Emergency Contact Person(s)
1. _________________________________________________________________________________
(Name, Address, Home and Cell Phone #)
2. _________________________________________________________________________________
(Name, Address, Home and Cell Phone #)
Emergency Medical Treatment
I hereby give ____________________________________________________________ permission to
(Name of provider/assistant)
administer basic first aid and/or CPR to my child _____________________________________________
(Name)
and/or take my child _______________________________________, to a hospital for medical treatment
(Name)
when I cannot be reached or when delay would be dangerous to my child's health.
_______________________________________
Parent/Guardian

_________________________________________
Date

Medical Insurance Information (Optional)

Subscriber's Name:____________________________________________________________________
Type of Insurance:_____________________________________________________________________
Policy Number:_______________________________________________________________________
Other pertinent medical information:_______________________________________________________
____________________________________________________________________________________

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Dear Physician:
_________________________________ is enrolled in a family child care home which is licensed by the
Department of Early Education and Care. The Department of Early Education and Care regulations
require that the Medical History form be completed and signed by the childs physician or source of health
care. Additionally, evidence that the child has been successfully immunized in accordance with the
current Department of Public Healths recommended schedules must be submitted and signed by the
physician or source of health care.
Evidence of a physical exam is valid for one year from the date the child was examined and shall be
renewed annually thereafter.
IDENTIFICATION
Name of Child: ______________________________ Date of Birth: _____________________________
Address: ________________________________________________ Phone # ____________________
Name of Parents/Guardians: ____________________________________________________________
Address: ____________________________________________________________________________
Date of Examination of Child: ____________________________________________________________
What is your opinion concerning the child's general health and appearance: _______________________
____________________________________________________________________________________
____________________________________________________________________________________
Has this child been screened for lead poisoning? Yes ________ No _________
If Yes, Date screened: _______________
Does this child have any disabilities or chronic medical problems (allergies, limited vision, etc.) which
require special consideration or care by the child care provider? If so, please detail below:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Physician's Signature: __________________________________________________________________
Date: ___________________ Comments: _________________________________________________

Please return this form and the childs immunization record to:

Name of Provider: ____________________________________________

____________________________________________
____________________________________________

THE PROVIDER MAY ACCEPT FROM THE PARENTS OF SCHOOL AGE CHILDREN A WRITTEN
STATEMENT THAT THE REQUIRED INFORMATION IS ON FILE WITH THE CHILDS SCHOOL.
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